NR 509 Midterm with Updated Solutions
A patient presents for evaluation of a sharp, aching chest pain which increases with breathing.
Which anatomic area would you localize the symptom to?
A) Musculoskeletal
B) Reproductive
C) Urinary
D) Endocrine - CORRECT ANSWER A) Musculoskeletal
Chest pain may be due to a musculoskeletal condition, such as costochondritis or
intercostal muscle cramp. This would be worsened by motion of the chest wall. Pleuritic chest
pain is also a sharp chest pain which increases with a deep breath. This type of pain can
occur with inflammation of the pleura from pneumonia or other conditions and pulmonary
embolus.
A patient comes to the emergency room for evaluation of shortness of breath. To which anatomic
region would you assign the symptom?
A) Reproductive
B) Urinary
C) Cardiac
D) Hematologic - CORRECT ANSWER C) Cardiac
Cardiac disorders such as congestive heart failure are the most likely on this list to result in
shortness of breath. There are cases within the other categories which may also result
in shortness of breath, such as anemia in the hematologic category, pregnancy in the reproductive
category, or sepsis with UTI in the urinary category.
A patient presents for evaluation of a cough. Which of the following anatomic regions can be
responsible for a cough?
A) Ophthalmologic
B) Auditory
C) Cardiac
D) Endocrine - CORRECT ANSWER C) Cardiac
The cardiac system can cause a cough if the patient has congestive heart failure. This results in
fluid buildup in the lungs, which in turn can cause a cough that produces pink,
frothy sputum. A foreign body in the ear may also cause a cough by stimulating Arnold's branch
of the vagus nerve, but this is less likely to be seen clinically than heart failure.
A 22-year-old advertising copywriter presents for evaluation of joint pain. The pain is new,
located in the wrists and fingers bilaterally, with some subjective fever. The patient denies a
rash; she also denies recent travel or camping activities. She has a family history significant for
,rheumatoid arthritis. Based on this information, which of the following pathologic processes
would be the most correct?
A) Infectious
B) Inflammatory
C) Hematologic
D) Traumatic - CORRECT ANSWER B) Inflammatory
The description is most consistent with an inflammatory process, although all the other etiologies
should be considered. Lyme disease is an infection which commonly causes
arthritis, hemophilia is a hematologic condition which can cause bleeding in the joints, and
trauma can obviously cause joint pain.
A 47-year-old contractor presents for evaluation of neck pain, which has been intermittent for
several years. He normally takes over-the-counter medications to ease the pain, but this time they
haven't worked as well and he still has discomfort. He recently wallpapered the entire second
floor in his house, which caused him great discomfort. The pain resolved with rest. He denies
fever, chills, rash, upper respiratory symptoms, trauma, or injury to the neck. Based on this
description, what is the most likely pathologic process?
A) Infectious
B) Neoplastic
C) Degenerative
D) Traumatic - CORRECT ANSWER C) Degenerative
The description is most consistent with degenerative arthritis in the neck. The
patient has had intermittent symptoms and the questions asked to elicit pertinent negative and
positive findings are negative for infectious, traumatic, or neoplastic disease.
A 15-year-old high school sophomore comes to the clinic for evaluation of a 3-week history
of sneezing; itchy, watery eyes; clear nasal discharge; ear pain; and nonproductive cough. Which
is the most likely pathologic process?
A) Infection
B) Inflammation
C) Allergic
D) Vascular - CORRECT ANSWER C) Allergic
This description is most consistent with allergic rhinitis.
A 19-year old-college student presents to the emergency room with fever, headache, and
neck pain/stiffness. She is concerned about the possibility of meningococcal meningitis.
Several of her dorm mates have been vaccinated, but she hasn't been. Which of the following
physical examination descriptions is most consistent with meningitis?
A) Head is normocephalic and atraumatic, fundi with sharp discs, neck supple with full range
,of motion
B) Head is normocephalic and atraumatic, fundi with sharp discs, neck with paraspinous
muscle spasm and limited range of motion to the right
C) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck tender to
palpation, unable to perform range of motion
D) Head is normocephalic and atraumatic, fundi with blurred disc margins, neck supple with
full range of motion - CORRECT ANSWER C) Head is normocephalic and atraumatic, fundi
with blurred disc margins, neck tender to
palpation, unable to perform range of motion
Blurred disc margins are consistent with papilledema, and neck tenderness and lack of range of
motion are consistent with neck stiffness, which in this scenario is likely to be caused
by meningeal inflammation. Kernig's and Brudzinski's signs are also helpful in testing for
meningeal irritation on exam.
A 37-year-old nurse comes for evaluation of colicky right upper quadrant abdominal pain. The
pain is associated with nausea and vomiting and occurs 1 to 2 hours after eating greasy foods.
Which one of the following physical examination descriptions would be most consistent with the
diagnosis of cholecystitis?
A) Abdomen is soft, nontender, and nondistended, without hepatosplenomegaly or masses.
B) Abdomen is soft and tender to palpation in the right lower quadrant, without rebound or
guarding.
C) Abdomen is soft and tender to palpation in the right upper quadrant with inspiration, to the
point of stopping inspiration, and there is no rebound or guarding.
D) Abdomen is soft and tender to palpation in the mid-epigastric area, without rebound or
guarding. - CORRECT ANSWER C) Abdomen is soft and tender to palpation in the right upper
quadrant with inspiration, to the
point of stopping inspiration, and there is no rebound or guarding.
In cholecystitis, the pain, which originates from the gallbladder, is located in the
right upper quadrant. Severity of pain with inspiration that is sufficient to stop further inhalation
is also known as Murphy's sign, which, if present, is further indicative of inflammation of the
gallbladder.
A 55-year-old data entry operator comes to the clinic to establish care. She has the following
symptoms: headache, neck pain, sinus congestion, sore throat, ringing in ears, sharp brief chest
pains at rest, burning abdominal pain with spicy foods, constipation, urinary frequency that is
worse with coughing and sneezing, and swelling in legs. This cluster of symptoms is explained
by:
A) One disease process
B) More than one disease process - CORRECT ANSWER B) More than one disease process
The patient appears to have several possible conditions: allergic rhinitis, arthritis,
, conductive hearing loss, pleuritic chest pains, heartburn, stress urinary incontinence, and venous
stasis, among other conditions. Although we always try, it is very difficult to assign all of these
symptoms to one cohesive diagnosis.
A 62-year-old teacher presents to the clinic for evaluation of the following symptoms: fever,
headache, sinus congestion, sore throat, green nasal discharge, and cough. This cluster of
symptoms is best explained by:
A) One disease process
B) More than one disease process - CORRECT ANSWER A) One disease process
This cluster of symptoms is most consistent with sinusitis. The chance that all of these symptoms
are caused by multiple synchronous conditions in the same patient is much less than the
possibility of having one problem which accounts for all of them.
Steve has just seen a 5-year-old girl who wheezes when exposed to cats. The patient's family
history is positive for asthma. You think the child most likely has asthma. What have you just
accomplished?
A) You have tested your hypothesis.
B) You have developed a plan.
C) You have established a working diagnosis.
D) You have created a hypothesis. - CORRECT ANSWER D) You have created a hypothesis.
As you go through a history and examination, you will start to generate ideas to explain the
patient's symptoms. It is best to keep an open mind and make as many hypotheses
as you can, to avoid missing a possibility. A common mistake is to latch onto one idea too early.
Ms. Washington is a 67-year-old who had a heart attack last month. Now she complains of
shortness of breath and not being able to sleep in a flat position (orthopnea). On examination you
note increased jugular venous pressure, an S3 gallop, crackles low in the lung fields, and swollen
ankles (edema). This is an example of a:
A) Pathophysiologic problem
B) Psychopathologic problem - CORRECT ANSWER A) Pathophysiologic problem
This is an example of a pathophysiologic problem because Ms. Washington's
symptoms are consistent with a pathophysiologic process. The heart attack reduced the ability of
her heart to handle her volume status and subsequently produced the many features of congestive
heart failure.
On the way to see your next patient, you glance at the calendar and make a mental note to
buy a Mother's Day card. Your patient is Ms. Hernandez, a 76-year-old widow who lost her
husband in May, two years ago. She comes in today with a headaches, abdominal pain, and
general malaise. This happened once before, about a year ago, according to your detailed office
notes. You have done a thorough evaluation but are unable to arrive at a consistent picture to
